If no, are you a Lawful Permanent resident alien? STATEMENT OF PERSONAL HISTORY (FOR USE BY NON-BANK LENDERS, CERTIFIED DEVELOPMENT COMPANIES, AND MICROLENDERS) SBA Form 1081 (10-03) Previous Edition is Obsolete OMB APPROVAL NO.: 3245-0080 EXPIRATION DATE: 12/31/2006 U.S. Small Business Administration Name of Non-Bank Lender, Certified Development Company, or Microlender Address (Street, City, State and Zip Code) of Non-Bank Lender, Certified Development Co., or Microlender 1. Applicant's Name in Full: First Middle Name (if none, so state) Last Date of Birth (month, day & year) 2. 3. Place of Birth (City and State or Foreign Country) Starting with present address, attach a list of residence addresses for the last ten years using the following format : 6.T 1 From (Date) To (Date) Address Employment and Professional History and Education: Attach a summary of (a) business or professional experience during the last ten years up to and including the present, stating the periods of each primary activity; the names, addresses and nature of business of the concerns or entities with which associated; title/and position in such concerns; and basic functions and responsibilities; (b) summary of your education showing highest level attained (such as high school graduate, bachelor's degree, master's degree, etc.--giving, when applicable, name of higher educational institution, your specialization, and date of degree); and (c) a summary of any special experience or qualifications pertinent to responsibilities in connection with the operation of the Non-Bank Lender, Certified Development Company, and Microlenders. 7. Present Affiliations: Attach a list of all business concerns with which you are presently affiliated as an officer, director, or in any other official capacity, or by way of direct or indirect ownership or control of 10% or more of any class of, stock of, or proprietary interest in, such concerns. Show names, addresses, and nature of business of such concerns, and details of relationships and ownership, including the percentage of any stock or proprietary interest owned. 8. Have you ever been, directly or indirectly, the subject of an insolvency, bankruptcy, or creditor's rights proceedings, or has any corporation of which you have been an officer, director, or controlling shareholder been the subject of such proceedings? (If yes, furnish complete details of such proceedings in a separate exhibit, including, if pertinent, the court, title of proceedings, date and docket number, as well as the ultimate disposition.) 9. Yes No 10a. Are you presently under indictment, on parole or probation? Yes No 4. U.S. Citizen? No Yes 5. Social Security Number: Have you ever been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which have been dismissed, discharged or not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet) 10b.Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for any criminal offense other than a minor vehicle violation? 10c. (If yes, indicate date parole or probation is to expire.) If non -U.S. citizen provide alien registration number:11. Yes No 12. Have you ever been refused bond? (If yes, explain.) 13.Are you associated with any other Non-Bank Lender, Certified Development Company, or Microlender? (If yes, explain.) 14. During any part of the past five years has a request for financial assistance been made to any Federal agency by you or any corporation, partnership or other business entity with which you are presently or have been heretofore affiliated (as defined in Item 8, Page 1)? (If yes, furnish details in a separate exhibit, including current status of any assistance received.) 15.To your knowledge, is any SBA employee or any member of an Advisory Council for the Small Business Administration related to you by blood, marriage, or adoption and/or associated with you through having any past or present, direct or indirect, financial interest in or affiliation with any concern of which you are a director, officer or owner of 10% or more of any class of its stock or other proprietary interest? (If yes, list their names, addresses, and relations.) 16. If you own or will own 10% or more of any class of the stock of the Non-Bank Lender, Certified Development Company, or Microlender were borrowed funds used in purchasing said stock? (If yes, give full details including your net worth, amount borrowed or to be borrowed, security and/or guarantors and terms of repayment.) 17. Has any concern with which you are affiliated directly or indirectly borrowed funds from any Non-Bank Lender, Certified Development Company, or Microlender? (If yes, give all pertinent details including the names of all parties to the transaction, the amounts involved, terms, use of proceeds, etc.) The information on this form will be used in connection with an investigation of your experience and character. It is against SBA policy to provide assistance not in the best interests of the United States, i.e., if there is reason to believe that the effect of such assistance will be to encourage or support, directly or indirectly, activities inimical to the security of the United States. The nature and scope of the investigation may include contact with banks, other financial institutions, individuals, business associates, law enforcement offices, and any other areas which will assist SBA in making an adequate appraisal of your business reputation, character, management experience and financial soundness. This constitutes the notification required by Section 606 of the Federal Fair Credit Reporting Act. Certificate: I hereby certify that the foregoing is true and complete to the best of my knowledge and belief. Signature Title Date SBA Form 1081 (10-03) Previous Edition is Obsolete PLEASE NOTE: The estimated burden for completing this form is 30 minutes per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington, D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0080). PLEASE DO NOT SEND FORMS TO OMB. FOR SBA USE ONLY No. Have you, or has any corporation, partnership or other business entity with which you are presently or have heretofore been affiliated (as defined in Item 8, Page 1), ever been charged with or convicted of a felony or other criminal offense involving dishonesty or breach of trust, or found civilly liable or permanently or temporarily enjoined by a court by reason of any act or practice involving fraud or breach of trust? (If yes, furnish relevant details of any such proceedings in a separate exhibit, including the information, indictment or complaint and the court, title of proceedings, date and docket number.) CAUTION: Knowingly making a false statement on this form is violation of Federal law and could result in criminal prosecution, significant civil penalties punishable under 18 USC 1001 by imprisonment of not more than five years and/or a fine of not more than $10,000; and under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000. I authorize the Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act.Privacy Act (5 U.S.C. 552a) You can request to see or get copies of any personal information that we have in your file, when that file is retrieved by individual identifiers, such as name or social security numbers. Request for information about another party may be denied unless we have the written permission of the individual to release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. While generally, under the provisions of the Privacy Act, you are not required to provide social security number and the failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled, the Debt Collection Act of 1982 requires each person doing business with that agency to furnish such persons tax identification numbers. Additionally, disclosures of name and other personal identifiers are benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for SBA ro make a character determination. However, we require an individual seeking assistance to provide sufficient information for us to make a credit, eligibility and character determination. As a result, if you do not provide your social security number and other personal identifiers, we will not have sufficient information upon which to reach favorable determinations. Debt Collection Improvement Act of 1996 (31 U.S.C. & 7701(c)(1) This law permits a Federal agency to require each person doing business with that agency to furnish to that agency that person's taxpayer identification number. Freedom of Information Act (5 U.S.C & 552) This law provides, with some exceptions, that we must make records or portions of records contained in our files available to persons requesting them. This generally includes aggregate statistical information on our loan programs and other information such as names of borrowers (and their officers, directors, stockholders or partners), loan amounts at maturity, the collateral pledged, and the general purpose of loans. We do not routinely make available to third parties your proprietary data without first doing pre-notification or information that would cause competitive harm or constitute a clearly unwarranted invasion of personal privacy. SBA Form 1081 (10-03) Previous Edition is Obsolete To request information under the Act, you must send the request to the SBA office maintaining the records requested and identify it as a Freedom of Information Act (FOIA) request. The request must describe the specific records you want. For information about the FOIA, contact the Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416, or by e-mail at foia@sba.gov. Paperwork Reduction ct (44 U.S.C. Chapter 35) SBA is collecting the information on this form to make a character determination regarding associates of non-bank lenders, certified development companies or micro-lenders. The information is required in order for SBA to have sufficient information to determine whether to provide the organization with the required assistance. The information collected may be checked against criminal history indices of the Federal Bureau of Investigation. An associate of a lender is defined as an officer, director, key employee, or holder of 20 percent or more of the value of the Lender's stock or debt instruments, or an agent involved in the loan process (title 13, code of federal regulations, part 120.10, definitions).